Much ado about Meckel’s

Cite this article as:
Peter Tormey. Much ado about Meckel’s, Don't Forget the Bubbles, 2021. Available at:

Robert is a 14-year-old boy who re-presents to ED with a history of rectal bleeding. He has had four or five episodes of passing bright, red blood PR over the last three days, having been a previously well child. He has also had four or five episodes of non-bilious vomiting.

Mum has noticed that he has now become pale and lethargic.

On his first presentation to ED, two days prior, the working diagnosis was bacterial gastroenteritis. His haemoglobin at that time was 99g/L. It has fallen to 45g/L on this presentation.

On examination, he is very pale, his heart rate is 120, and his blood pressure 95/65.

What are your differentials at this point?


  • Bacterial: Campylobacter, Salmonella, Shigella, E. coli, Yersinia, C. difficile
  • Viral: rotavirus, COVID-19


  • Inflammatory bowel disease


Bowel obstruction

  • Intussuception
  • Malignancy


  • Meckel’s diverticulum
  • Anal fissure
  • Haemorrhoids
  • Trauma/NAI

What investigations would you perform?

  • Bloods: FBC, U+E, LFTs, CRP, ESR, VBG, blood culture, coagulation screen
  • Stool culture, stool for C.difficile
  • Covid swab
  • Abdominal ultrasound
  • CT abdomen/pelvis
  • Colonoscopy
  • Meckel’s scan

What is Meckel’s Diverticulum?

You may remember “The Rule of Two’s” from medical school.

MD is a congenital abnormality of the small intestine that is present in 2% of the population. 2% of these people will become symptomatic. It is 2 inches long and 2 feet from the ileocoecal valve. There can be 2 types of ectopic tissue: gastric or pancreatic. There is a 2:1 male preponderance.1,2,3

MD comprises the three layers of the intestinal wall and is, therefore, a true diverticulum.3 It results from the incomplete obliteration of the omphalomesenteric duct. The omphalomesenteric duct connects the yolk sac to the intestinal tract during early foetal life and is usually obliterated by the seventh week of gestation. Failure to regress can result in a spectrum of abnormalities, including: MD, patent vitelline duct, fibrous band, sinus tract, umbilical polyp and umbilical cyst.3

Comparison between vitelline fistula and meckel's

What happens to the symptomatic 2%?

The presentation of MD is highly variable. It is best to consider the different presentations based on the underlying anatomical or pathological processes the diverticulum can undergo.

1. It gets in the way

The abnormal anatomy in MD can lead to intestinal obstruction. In children, this usually presents as intussusception or volvulus.3

The diverticulum acts as the lead point in intussusception. These patients present with abdominal pain. The symptoms can be non-specific, particularly in pre-verbal children. They are “off form”, or parents complain about poor feeding, constipation, abdominal distension. As you can see from Robert’s case, intussusception can also lead to massive GI haemorrhage.

Volvulus of the intestine may occur around the fibrous cord that connects the Meckel’s to the umbilicus.4

2. The ectopic gastric tissue can cause an ulcer

The ectopic gastric mucosa in the diverticulum can secrete acid which results in ulceration of the small bowel. This usually presents as painless bleeding, which can be massive in nature.3 It may also present due to anaemia from chronic bleeding. The bleeding is usually dark red or maroon in colour.3 Robert’s Technitium-99m scan (or Meckel’s scan) was positive, suggesting the presence of gastric mucosa, so he may have intussusception plus ulceration, both leading to his massive GI haemorrhage.

3. It gets angry

As the Meckel’s is a blind ending diverticulum, it can undergo a process of inflammation, similar to appendicitis. Obstruction at the base of the diverticulum leads to bacterial overgrowth and inflammation. This can present with fever, vomiting and abdominal pain, which is often indistinguishable from acute appendicitis. The MD may also perforate, leading to diffuse peritonitis and  a very unwell patient.

As these symptoms are all non-specific, it is important to think of MD as a diagnosis in children presenting with any of the symptoms above.

How is it diagnosed?

MD requires a high index of clinical suspicion to aid diagnosis. Most imaging modalities are non-specific but can still be helpful. X-ray or ultrasound may show a small bowel obstruction and intussusception.5 Finding a normal appendix on ultrasound, may lead to careful consideration of MD as an alternate cause.

A Meckel’s scan may be performed. This is a nuclear medicine scan using Technitium-99m, which accumulates in the ectopic gastric mucosa (see Image 2).5 The test is reliant on the presence of gastric mucosa, which is only present in 4.6-71% of symptomatic MD.5 Premedication with H2 antagonists may increase the accuracy of the scan.5

Radionuclide Meckel scan
Case courtesy of Radswiki, From the case rID: 11598

MD is often only confirmed on exploratory laparoscopy or laparotomy.

How is it treated?

Definitive treatment is surgical resection of the diverticulum, either laparoscopically or by laparotomy. Simple diverticulectomy and closure of the ileum is acceptable except in cases of GI bleeding where the ulcer may extend to the adjacent ileum, in which case segmental resection with re-anastomosis of the small bowel should be carried out.4

Robert’s haemoglobin is 45. He requires multiple transfusions with packed red cells, FFP and fibrinogen. He is stabilized and transferred to PICU.

He has an emergency OGD and colonoscopy. They do not reveal the source of bleeding. His abdominal ultrasound shows a small bowel intussusception, suspicious for Meckel’s diverticulum (MD). He has a Meckel’s scan which confirms MD. He undergoes surgical resection of the diverticulum and recovers well.

Who was Meckel?

Johann Friedrich Meckel (the younger) was a German anatomist whose principle interest was the study of congenital malformation and the developmental aspects of the lungs and bloods vessels.6

Interestingly, MD was first described by Wilhelm Fabricius Hildanus, a German Surgeon, in 1598.7 It wasn’t named, however, until Meckel reported his research on the diverticulum’s anatomy and embryology in 1809.

He is also responsible for the medical eponyms Meckel cartilage and Meckel syndrome.

He is called Johann Friedrich Meckel The Younger because his grandfather was called by the same name and was also an anatomist, as were his father, younger brother and son.

You can find out more about him and the Meckel anatomist dynast on LITFL.

References for Much Ado about Meckel’s

1. Meckel’s Diverticulum [Internet]. [cited 2021 Apr 1]. Available from:

2. Rule of 2s in Meckel diverticulum | Radiology Reference Article | [Internet]. [cited 2021 Apr 1]. Available from:

3. Keese D, Rolle U, Gfroerer S, Fiegel H. Symptomatic Meckel’s Diverticulum in Pediatric Patients—Case Reports and Systematic Review of the Literature. Front Pediatr [Internet]. 2019 Jun 26 [cited 2021 Apr 12];7(JUN):267. Available from:

4. Ivatury RR. Meckel’s diverticulum and the eponymous legend. Vol. 87, Journal of Trauma and Acute Care Surgery. Lippincott Williams and Wilkins; 2019. p. 451–5.

5. Hansen C-C, Søreide K. Systematic review of epidemiology, presentation, and management of Meckel’s diverticulum in the 21st century. Medicine (Baltimore) [Internet]. 2018 Aug 1 [cited 2021 Apr 12];97(35):e12154. Available from:

6. Johann Friedrich Meckel The Younger • LITFL • Medical Eponym Library [Internet]. [cited 2021 Apr 12]. Available from:

Crash course in feeding tubes

Cite this article as:
Georgina Bough, Ana Waddington, Rachel Radley and Rebecca McConnell. Crash course in feeding tubes, Don't Forget the Bubbles, 2021. Available at:

Flatter tubes

Gastrostomy button (Low profile balloon gastrostomy e.g. MIC-KEY button®, MiniONE button®)

Gastro-jejunostomy button (G-J button e.g. MIC-KEY gastro-jejunal feeding tube®)

Dangly tubes:

PEG tube (e.g. Freka® PEG, CorFlo® PEG)

PEG-J tube: (e.g. Freka® PEG-J, CorFlo® PEG-J)

Balloon gastrostomy (e.g. MIC gastrostomy®):

Ok, got that … Troubleshooting

Complications often depend on the type of tube – balloon or PEG, gastrostomy or gastrojejunostomy.

Tube has fallen out

This is probably the most common ED problem. They tend to be a balloon tube (the balloon bursts) and then it’s an urgent problem. If the tract is left empty it will close up in hours and may need a laparotomy to replace the tube.

Replace the tube if you can (family will often have a spare and many will do this at home). Otherwise put a foley catheter in the tract, tape it to the skin and call the relevant surgical team if you can’t replace the tube.

Lie the child down on the bed, bring a selection of catheters (6Fr, 8Fr, 10Fr, 12Fr) and lots of lube, aim to gently place the largest catheter that will go in, insert about 5cm in a larger child, 3cm in a smaller child. Tape the tube securely to the tummy.

DO NOT do this if this is a primary balloon gastrostomy.  See below.

The jejunal part has fallen out / flipped up

Again this is an urgent problem. The family may report milk coming back through the gastric port/ milky vomiting, a PEG-J that is strangely easy to flush, a tube that looks different to normal or a jejunal tube in the nappy or stoma bag!

PEG-J’s are made from different parts.  The jejunal tube is fed through the gastric part and can fall off (into the patient).  This can be confirmed on x-ray and a radiologist will need to re-thread a new jejunal tube. The old tube will usually pass out per rectum or via a stoma. Don’t use the jejunal part of the tube until it has been replaced.

Balloon gastro-jejunostomies are made as one piece but the jejunal end can flip back into the stomach (can be confirmed on x-ray). A radiologist will need to re-site the tube. Don’t use the jejunal part of the tube until it has been re-sited.

The tube is leaking / split

Leaking from skin level

This can happen if the child is unwell and the gastric motility is reduced (higher than normal pressure in the stomach). 

Is the PEG/PEG-J loose? If the tube moves in and out a lot, pulling it snug and securing the flange may stop the leak.  

Balloon tubes may have too little water so changing the water and adding 1ml may help. Padding the tube with a thick dressing or using a shorter tube may also help.

The family should have contact with a CNS who can help.

Leaking from further down the tube

This is often due to a split tube or connector on a PEG / PEG-J. It can be fixed without an anaesthetic as long as the split isn’t close to the skin. You need to find the parts that are specific to the tube, then cut the damaged part off and put a new end on – like DIY or Lego. Usually a nurse specialist or paediatric surgeon does this but knowing which tube the child has is essential.

The tube is blocked

This usually happens with longer tubes. Hospitals often have a protocol for unblocking, and there are a lot of hospital guidelines on the web. If simple measures don’t work change the tube (see below).

Skin problems

These can occur when a tube leaks, is infected or a granuloma forms. The family should have a CNS or enteral feeding nurse who should be able to help

  • Infection: swab the site for bacteria and fungi and treat. Use a dressing to stop the tube rubbing
  • Leaking: See leaking tube.  
  • Granuloma: Usually not an ED problem. More common in clinic or on the ward.


Tube typeDangly?Number of ends?How is it held in?Who changes it?
Gastrostomy buttonNo1BalloonAnyone trained (unless it is a primary gastrostomy button placed within 6 weeks, see below)
Gastro-jejunostomy buttonNo2BalloonPaediatric radiologist
PEGYes1 (varies by brand)Plastic discSurgeon/gastroenterologist
PEG-JYes2Plastic discIf jejunal part has fallen out - radiologist, if the whole thing is broken - surgeon/ gastroenterologist
MIC-G tubeYes1BalloonAnyone trained

** unless this is a primary gastrostomy button and was placed for the first time within 6 weeks. If a primary button falls out within 6 weeks call the surgical team who did the operation urgently.

a The PEG ends vary between brand. Here’s a couple of pictures of PEG tube ends and PEG-J ends for reference

Special cases

There are always exceptions! 

Primary gastrostomy buttons

Some surgeons create a new gastrostomy and use a button as the first tube (primary button). Many place a PEG first and then change the PEG for a button once the tract has healed. If a primary button falls out before the tract has healed (in the first 6 weeks) placing a new tube roughly could push the stomach away from the abdominal wall and leave the end of the tube in the peritoneum. After 6 weeks, the gastrostomy tract has healed and is like an ear piercing – you can change the tube without worrying where it will go. Ask the surgical history. The tract starts to form when it is first made, a general anaesthetic is required and they won’t have had a gastrostomy before then.  

Other uses for balloon gastrostomies

These are brilliant devices, they can be used in other ostomies e.g. vesicostomies, jejunostomies. Changing them is the same but they usually sit somewhere else in the abdomen (rather than in the left upper quadrant or epigastrium as gastrostomies do).

Other tubes

There are lots of other tube types out there and other brands including malecot tubes, Cor-flo PEGs. If in doubt ask a senior or your local friendly surgical registrar, if you can take a photo of the tube (with consent) this will help the conversation.

Combination tubes

As the PEG tubes can be assembled/disassembled like Lego® occasionally people will have odd-looking tubes.  This lass has a Corflo PEG end with a Freka securing device (external flange). Combination tubes should be the minority.

Crash course in stomas

Cite this article as:
Georgina Bough, Susan McDowell, Nikki Webber + Ana Waddington. Crash course in stomas, Don't Forget the Bubbles, 2021. Available at:

Thank you to the Paediatric Stoma Care guidebook 2019 written by The members of the Global Paediatric Stoma Nurses Advisory Board (GPSNAB).

You are working in A&E and a child comes in with a ‘funny looking stoma’. Parents have been told to come to ED because it’s the weekend and no speciality teams are available.  Where do you start?

Children, babies and even premature neonates can have a stoma.  A stoma is a surgically formed ‘mouth’ or opening into a hollow organ.

Do you know the difference between stomas?

Faecal Stoma

  • End ileostomy/colostomy
  • Loop ileostomy/colostomy
  • Stoma with mucous fistula

Urinary Stoma/ Diversions

  • Vesicostomy
  • Ileal conduit
  • Ureterostomies

Continence Stomas

  • Mitrofanoff/Monti
  • Antegrade continence enema (MACE/ACE)

Feeding Stomas

  • A gastrostomy or jejunostomy is a type of stoma, they often have the same problems as other stomas even though we often think of them in a different way.  They are covered in more detail here.

Why do Children/Young Adults need Stomas?

The majority of the stomas made in neonates and children are reversed.  The length of time with the stoma varies from a few months to a few years depending on the diagnosis, the situation, and the family and medical team’s preferences. 

Indications for faecal stoma


  • Anorectal malformation/ cloacal malformation:  A stoma (colostomy) is often formed to allow them to poo until the baby has the operation to create a new bottom.
  • Hirschsprung’s disease: Most babies with Hirschsprungs’ disease will be managed without a stoma but if the washouts don’t work a stoma (ileostomy) can be formed.  A stoma can also be formed as part of the operation to work out how much bowel is affected (a levelling stoma).
  • Necrotising enterocolitis (NEC): If a baby needs an operation for NEC they often need part of their intestine removed. Joining the ends may not be safe straight away.  They will then have a stoma (ileostomy/ jejunostomy).
  • Other causes of bowel injury in babies: Faecal stomas are also formed if a baby has a bowel blockage, bowel damage or perforation for another reason and the bowel cannot be safely joined back together at the first operation.  Other reasons include: small bowel atresia, malrotation and volvulus, meconium ileus.

Children / Young Adults

  • Constipation: Occasionally constipation is so bad that children need a continence stoma or a faecal stoma.  This can still be reversed in the future if it is not needed any more.
  • Inflammatory bowel disease: when medical management doesn’t work or in an emergency situation a stoma can be formed to divert the poo and rest the bowel.
  • Accidents: Occasionally in trauma a stoma can be formed as part of a damage-control laparotomy in a very sick child or when there is extensive damage to either the bowel, the pelvis or the bottom.  The stoma allows control of contamination (phase 1 DCS) before full resuscitation (and further investigations / operations).

Indications for urinary stomas

  • Posterior urethral valves: If a baby is born with posterior urethral valves is too small for cystoscopy and catheters aren’t an option a vesicostomy can be formed.
  • Neuropathic bladder: If a baby has a neuropathic bladder and catheterisation is not an option a vesicostomy allows the bladder to drain without creating a high pressure which can damage the kidneys
  • Trauma: Supra-pubic catheters are typically used to divert the urinary stream in trauma but other forms of urinary stomas are an option if a suprapubic catheter is not.

Continence stomas:

The appendix or a small piece of intestine can be used to make a tube that connects the bladder (Mitrofanoff / Monti-mitrofanoff) or bowel (ACE – antegrade continence enema) to the abdominal wall.  This forms a continent stoma (one that doesn’t leak) and allows a tube to be passed to drain urine or to give an enema.  This allows children who would otherwise be incontinent to be clean e.g. with severe constipation or a neuropathic bladder.

A beginners guide to stoma spotting

The aim is to work out what type of stoma this is (it is often written in the notes or the parents/carers know but that’s not the point!).  Helpful questions are: what is coming out of the stoma, how many holes does it have, does the end stick out and is it a happy stoma?

What is coming out?

How many holes does it have? 

Does the end stick out?

Is it a happy stoma?

What could have gone wrong?

Stoma complications either happen early after a stoma is formed or later.

  • Early – Necrosis, wound breakdown, infection,
  • Later – Prolapse, retraction, stricture, bleeding, granulation tissue, leakage around the bag/ bag not sticking.

What are the risks? 

  • Skin irritation Although the stoma itself has no sensation, the skin surrounding it does and it can become irritated by both the adhesive of the stoma bag, and also by the stool itself. Often, these irritations can be minor, but in some cases they can start to cause the skin to break down. The nursing staff and the stoma nurse specialists will observe for early signs of irritation.
  • Prolapse A prolapse is when the bowel becomes longer and protrudes through the opening of the stoma. Although this can be very frightening for parents, it is not usually serious. As long as the bowel remains pink and active, we will simply keep a close eye on it.
  • Retraction Retraction (also known as inversion or ‘moating’) of the stoma is when the stoma sinks below skin level. This can lead to problems with applying the bag. The nursing staff and stoma nurse specialists will have suggestions on how to help.
  • Bleeding The stoma will occasionally bleed, especially when touched. This is normal unless the bleeding does not stop. 

Trouble shooting

Not happy taking a stoma bag off

It can be intimidating taking off a stoma bag especially if you’re not happy putting it back.  The parents will often be expert at this even if they are reluctant to take the bag off because it is sore for the child.  It is worth having someone else come with you and having a camera to take a picture of the stoma (this can be the parent’s phone) so that the bag is only taken off once. Here’s a happy stoma bag change…

Leaking stoma bag

This can be really tricky to manage and stoma nurses are essential. Some basic tricks are: 

Make sure that the stoma bag is warm before you put it on – warm it up under your arm or in your pocket. This makes it more flexible and sticky and the seal will be better.  

Prepare, take your time and have enough help.  If the child is wriggling, changing a stoma bag is really hard so get all the kit together beforehand including plenty of cleaning supplies. Cut the new bag before you remove the old one and use stoma bag removing spray. Remember to dry the skin completely.

There are many products that are designed to help with different bags, fillers to even the skin around the stoma, powders to help the seal.

Make friends with your stoma nurse.  If they have written a plan follow it if at all possible.

Skin breakdown

When a bag leaks, is changed frequently or is cut poorly the skin around the stoma breaks down.  Barrier wipes / sprays and stoma removal sprays are a good start but it takes time and expert help to heal.

Rectal discharge

It is normal to have some rectal discharge after stoma formation. It can be due to leftover stool in the rectum, spill over from a loop stoma, ongoing mucous production from the bowel or diversion colitis.  If the discharge is foul smelling or bloody the medical team looking after the child should be made aware and can often help with diversion colitis.

High output faecal stoma

Stomas can have a high output if they are made close to the stomach or if the child is sick for any reason (like a form of diarrhoea).  It is important that they don’t get dehydrated, stoma losses >20ml/kg typically need replacing intravenously.  


Some stomas prolapse all the time (chronic) and some prolapse acutely.  If the stoma is pink and healthy and working (passing gas and stool/urine depending on the type of stoma) that is reassuring.  If it is not, then the child should be transferred urgently to a surgical centre.  If the stoma is acutely prolapsed then it should be reduced.  Put lignocaine gel / lots of sugar on the stoma to draw the swelling out, leave it alone for around 40 minutes and then try and push the stoma back5.  Sometimes the stoma will need an operation to revise it. If this is a chronic problem then revision is usually an elective procedure.

Poor growth

If the colon is bypassed by a stoma the body often doesn’t take up enough salt and this can slow growth. The serum sodium will be okay but in the urine they will be low.  It is worth checking a urinary sodium and supplementing with oral sodium if the levels are below 20mmol/l.

Selected references

1. Farrugia MK, Malone PS (2010) Educational article: The Mitrofanoff procedure. J Pediatr Urol 6:330–337.

2. Fracs SKK, Krois W, Lacher M, et al (2020) Optimal management of the newborn with an anorectal malformation and evaluation of their continence. Semin Pediatr Surg 150996.

3. Hutton KAR (2004) Management of posterior urethral valves. Curr Paediatr 14:568–575.

4. Okada T, Honda S, Miyagi H, Taketomi A (2011) Technical Points Regarding New Enterostomy Formation for Incarcerated Stomal Prolapse in Loop Enterostomy. Surg Sci 02:488–792.

5. Landim Júnior JA, Moura Júnior JV, Lima Forte HB, et al (2020) Topical osmotic therapy for a prolapsed incarcerated ostomy. J Pediatr Surg Case Reports 57:101454.

6. Forest-lalande L, Vercleyen S, Fellows J (2018) Paediatric stoma care: Global best practice guidelines for neonates, children and teenagers. 3–70

7. Holcomb III GW, Murphy JP, Ostlie DJ (2014) Ashcraft’s Pediatric Surgery, 6th ed. Elsevier Saunders

Trauma, Teams and Tribes: Vic Brazil at DFTB18

Cite this article as:
Team DFTB. Trauma, Teams and Tribes: Vic Brazil at DFTB18, Don't Forget the Bubbles, 2019. Available at:

Victoria Brazil is a senior staff specialist at the Gold Coast University Hospital. She is a world renowned expert in the role of simulation in medical education.

Thinking FAST, and slow

Cite this article as:
Andrew Tagg. Thinking FAST, and slow, Don't Forget the Bubbles, 2018. Available at:

10-year-old Elliott is brought into your emergency department after falling off his bike. Whilst trying to escape from a gang of bullies he went off-road, left the ground and landed awkwardly. The front wheel twisted and the handlebars hit his belly. He is complaining of pain in the left upper quadrant. He has been treated with intranasal fentanyl and is haemodynamically stable. Your registrar asks if he can do a FAST exam on him.


Basics principles of the FAST exam

The Focused Abdominal Sonography for Trauma exam superseded diagnostic peritoneal lavage in the late 1980s as a means of determining significant intra-abdominal free fluid. The actual monicker, FAST, was first used by Royzycki et al back in the mid-90s.

The FAST exam is a rapidly performed test that looks at four specific areas – RIGHT upper quadrant, LEFT upper quadrant, subxiphoid region, and pelvis. The wielder of the probe is looking for free fluid rather than directly looking for solid organ injury.

The 4 traditional FAST views – RUQ, LUQ, subxiphoid and pelvic.

It’s important to remember that the FAST exam came about as a tool to examine haemodynamically UNSTABLE patients in order to determine who needed to go to the operating theatre or needed a critical intervention (such as pericardiocentesis).

According to Rippey and Royce, the sensitivity of FAST in adults ranges from 64-98%. But…


What about in kids?

CT is considered the gold standard for the examination of intra-abdominal injury in children but it is not without risk. As clinicians we are reluctant to expose kids to needless radiation and try and act within the ALARA (As Low As Reasonably Possible) principle. With an increased focus on the use of point of care ultrasound throughout paediatrics it can be tempting to translate the adult approach of using the FAST scan, in kids.

A couple of concerns have been raised regarding the use of FAST in children:


Not all children with abdominal injuries have free fluid

A number of studies in haemodynamically stable children have found significant solid organ injuries (liver, spleen or kidney lacerations) on CT with normal bedside ultrasound. Whilst 22% of abdominal injuries in adults are not associated with free fluid this rises to a whopping 37% in children.

A 2007 meta-analysis by Holmes et al found an 80% sensitivity for detecting intra-peritoneal fluid via sonography. When the authors only looked at the more methodologically rigorous studies the sensitivity dropped to 66%.


The management of solid organ injuries in the paediatric population is different

Nearly all intra-abdominal injuries in children are managed conservatively and so accurate delineation is important. Finding free fluid on sonographic assessment does not mandate them going to theatre, even in the setting of haemodynamic instability. Operative management of hepatic injuries in children has been associated with higher mortality than a conservative approach.


So what does this all mean?

CT scanning does have its drawbacks – it involves ionising radiation, IV contrast and is time and money intensive in comparison with the FAST scan. But if ultrasound cannot tell us what we need to know then there is no comparison. A number of studies that have shown a better correlation between CT and US do not use the FAST scan but a modified form or even complete abdominal sonography by qualified sonographers. Given that US is very much an operator-dependent imaging modality it is vital that anyone using it has been trained (and accredited) in its use.

Emergency physicians may think they are amazing at performing a focused abdominal assessment and wield the probe at every given opportunity ‘for practice’. This will skew the accuracy of the test. If the pre-test probability of a positive result is low in the first place then the number of true negatives will, of course, be higher and the accuracy of the test will appear to be higher than it actually is.

In my attempt to trawl through some of the data I have consistently come across the idea that FAST is great because it is so accurate. The only way of knowing this is to look at the studies that compare it with a CT. Just because you do not pick up an injury immediately does not mean that one is not there. For example, in the Soudack et al. paper they described three negative FAST, positive CT cases – a haemo-peritoneum, one splenic laceration, and one hepatic laceration. Because the CT did not show free fluid these did not count as false-negatives!

A positive FAST is helpful but a negative one…not so much.


What do I do?

What I am really interested in is the Negative Predictive Value of the test i.e. the chance that if my scan is NEGATIVE there is NO free fluid. Unfortunately, a negative scan, in isolation does not tell me that there is not a significant intra-abdominal injury. In the setting of a worrying mechanism (e.g. handlebar versus spleen) with bruising and tenderness to the left upper quadrant and a NEGATIVE fast I cannot say that the child is okay and send them home. This is the concern that I have. That the test will stop the less astute clinician from thinking.

One has to be very wary when interpreting the literature surrounding FAST scans in paediatrics. All the scan tells you is that there is no free fluid. If the patient is haemodynamically stable and there is suspicion of an intra-abdominal injury then the patient should have a CT.

Haemodynamically stable patients

In the haemodynamically stable patient with an unconcerning physical exam, good quality images on a comprehensive abdominal ultrasound and the ability to serially examine the patient then a CT may not be warranted. A comprehensive abdominal ultrasound is NOT the same as FAST.

One might think that the use of ultrasound might have other benefits but a large study by Holmes et al. in 2017 showed no alteration in the number of CT scans requested, number of patients hospitalized or requiring surgery.


Haemodynamically unstable patients

These patients need resuscitation, often with blood products, until they are stable enough to enter the CT scanner/IR suite. A FAST scan is likely to be positive but given that over 90% of intra-abdominal injuries in children are managed without going to theatre it is unlikely to change my management.

Whilst this is clearly not a comprehensive review, any collection of data that has such a wide range of specificity needs to be considered. I could add another 10 studies and they might tighten up my spread but in the largest trials, involving ED physicians we are just not that great.

So the bottom line, when taken in isolation, as I see it is this best case/worst case…

Thanks to Arun Ilancheran and Ross Fisher for pushing me down this rabbit hole.


Selected references

Ashrafi A, Heydari F, Kolahdouzan M. The Utility of Ultrasound and Laboratory Data for Predicting Intra-abdominal Injury among Children with Blunt Abdominal Trauma. International Journal of Pediatrics. 2018 Aug 1;6(8):8047-59.

Calder BW, Vogel AM, Zhang J, Mauldin PD, Huang EY, Savoie KB, Santore MT, Tsao K, Ostovar-Kermani TG, Falcone RA, Dassinger MS. Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis. Journal of Trauma and Acute Care Surgery. 2017 Aug 1;83(2):218-24.

Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, Besner GE, Groner JI, Shiels WE. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. Journal of Trauma and Acute Care Surgery. 2000 May 1;48(5):902-6.

Emery KH, McAneney CM, Racadio JM, Johnson ND, Evora DK, Garcia VF. Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. Journal of pediatric surgery. 2001 Apr 1;36(4):565-9.

Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med 2011; 18:477– 482.

Holmes JF, Brant WE, Bond WF, Sokolove PE, Kuppermann N. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. Journal of pediatric surgery. 2001 Jul 1;36(7):968-73.

Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, Tancredi DJ, Kuppermann N. Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial. Jama. 2017 Jun 13;317(22):2290-6.

Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. Journal of pediatric surgery. 2007 Sep 1;42(9):1588-94.

Kessler DO. Abdominal Ultrasound for Pediatric Blunt Trauma: FAST Is Not Always Better. Jama. 2017 Jun 13;317(22):2283-5.

Menaker J, Blumberg S, Wisner DH, Dayan PS, Tunik M, Garcia M, Mahajan P, Page K, Monroe D, Borgialli D, Kuppermann N. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. Journal of Trauma and Acute Care Surgery. 2014 Sep 1;77(3):427-32.

Moore C, Liu R. Not so FAST—let’s not abandon the pediatric focused assessment with sonography in trauma yet. Journal of thoracic disease. 2018 Jan;10(1):1.

Murphy R, Ghosh A. The accuracy of abdominal ultrasound in paediatric trauma. Emergency medicine journal: EMJ. 2001 May;18(3):208.

Mutabagani KH, Coley BD, Zumberge N, McCarthy DW, Besner GE, Caniano DA, Cooney DR. Preliminary experience with focused abdominal sonography for trauma (FAST) in children: is it useful?. Journal of pediatric surgery. 1999 Jan 1;34(1):48-54.

Retzlaff T, Hirsch W, Till H, Rolle U. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma?. Journal of pediatric surgery. 2010 May 1;45(5):912-5.

Rippey JC, Royse AG. Ultrasound in trauma. Best Practice & Research Clinical Anaesthesiology. 2009 Sep 1;23(3):343-62.

Rozycki GS, Ochsner MG, Jaffin JH & Champion HR. Prospective evaluation of surgeons’ use of ultrasound in the evaluation of trauma patients. The Journal of Trauma 1993 Apr; 34(4): 516–526. discussion 26–7.

Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. Journal of pediatric surgery. 2013 Jun 1;48(6):1377-83.

Schonfeld D, Lee LK. Blunt abdominal trauma in children. Current opinion in pediatrics. 2012 Jun 1;24(3):314-8.

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Stabbings in adolescents

Cite this article as:
Tessa Davis. Stabbings in adolescents, Don't Forget the Bubbles, 2018. Available at:

It’s a regular day in your Paeds ED. You’ve just pulled a piece of lego out of a child left nostril; there are two wheezy kids waiting for review to see if they can stretch to two hours; and there is a 2 month old with a rash that you’re currently seeing  – everyone is waiting for you to come up with a clever diagnosis. As you stare at the spots and wait for some inspiration, you hear one of your nursing colleagues call…

Ross Fisher: What surgeons wish you knew from DFTB17

Cite this article as:
Team DFTB. Ross Fisher: What surgeons wish you knew from DFTB17, Don't Forget the Bubbles, 2018. Available at:

This talk was recorded live on the final of DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at

What more can be said about Ross Fisher that hasn’t already been said? Passionate presenter, good (but not perfect*) surgeon and friend to the stars – in this talk Ross delves into the hidden world of paediatric surgery.

Camille Wu: Testicular Troubles at DFTB17

Cite this article as:
Team DFTB. Camille Wu: Testicular Troubles at DFTB17, Don't Forget the Bubbles, 2018. Available at:

This talk was recorded live on the final of DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at

Camille Wu is a paediatric surgeon based out of Sydney. Here she talks about those things that make grown men go weak at the knees.

Craig McBride: Minimally Invasive Surgery at DFTB17

Cite this article as:
Team DFTB. Craig McBride: Minimally Invasive Surgery at DFTB17, Don't Forget the Bubbles, 2018. Available at:

This talk was recorded live on the final of DFTB17 in Brisbane. If you missed out in 2017 then why not book your leave for 2018 now. Tickets are on sale for the pre-conference workshops as well as the conference itself at

Craig McBride is a paediatric surgeon at Lady Cilento in Brisbane. Here he talks about how we have moved on from the days of maximally invasive surgery when a barber-surgeon was not judged on the neatness of their sutures but on the sharpness of their blade.

Treadmill Burns

Cite this article as:
Henry Goldstein. Treadmill Burns, Don't Forget the Bubbles, 2016. Available at:

Chase, 3, is brought in by ambulance with his hand wrapped in a towel. His sweaty father – wearing running gear – explains that Chase touched the treadmill whilst Dad was in full flight.

A recently published paper in Burns reviews the epidemiology of treadmill burns;

Goltsman D, Li Z, Connolly S, Meyerowitz-Katz D4, Allan J, Maitz PK Pediatric Treadmill Burns: Assessing the effectiveness of prevention strategies.Burns. 2016 Aug 10. pii: S0305-4179(16)00064-4. doi: 10.1016/j.burns.2016.02.007. [Epub ahead of print]

Goltsman and colleagues reviewed a set of 298 treadmill burns sustained over a 10 year period in NSW, Australia.

Treadmills seem oddly specific, why the focus? Treadmill burns deserve our attention for three reasons;


Firstly, they are relatively common in the paediatric population, accounting for around 1 in 20 burns.

They’re most common in the 0-5 age group (mean age – 3.8yrs)

More often males; 62%

Treadmill burns are classically small, at less than 1% TBSA.

85% were burns to the hand, with a total of 91% being somewhere on the upper limb.

The lower limb, torso and head & neck each accounted for 4%, 5% and 7% of treadmill burns, respectively.


Secondly, the pathophysiology of treadmill burns is complex.

The basic mechanism is friction. Often, there is also entrapment of limbs, fingers or toes causing extensive and penetrating burns. Blunt trauma may occur when a child falls off the machine.

It is postulated that friction burns in children are particularly severe as their withdrawal reflex is relatively developmentally immature, and their volar epidermis is thinner. In concert, the slow reflex leads to prolonged burn time through more vulnerable skin.

In this data set, 62% of burns were full thickness.


 Three quarters of the treadmill burns reviewed received no or inadequate first aid. First aid should be provided as per a typical thermal injury with 20 minutes of cool running water.

A significant number require reconstructive surgery; half the patients who sustained a treadmill burn received skin grafts.

An entrapment injury sustained whilst the treadmill was operating was more likely to require grafting.

How might we reduce the prevalence of treadmill burns?

The study data was obtained at a time when legislative changes led to mandatory safety warnings on treadmills. In addition to a multimodal public health campaign, there was a decrease in the annual number of treadmill burns throughout the study period. Yet, the most recent data (from 2014) still sees treadmill burns account for 4% of all paediatric burns.

Goltsman et al., moot the following suggestions to further reduce the risk of treadmill burns in children;

1. Safety devices could make it impossible for a child to start a treadmill;

2. Treadmills could have sensors in the area of danger for friction burns to automatically stop in case a body part gets trapped there;

3. The ‘‘stop’’ mechanism should be easy to reach even after a person has fallen from the treadmill, not just from a standing position; or

4. In order to prevent parents who are using the treadmill from failing to notice children standing or crawling right next to them behind the treadmill, the running treadmill could stop, or play an ‘‘alarm’’ noise if anyone comes close.

This study compliments and earlier review undertaken by Jermijenko et al in 2008;

Jeremijenko L, Mott J, Wallis B, Kimble R. Paediatric treadmill friction injuries. J Paediatr Child Health. 2009 May;45(5):310-2. doi: 10.1111/j.1440-1754.2008.01329.x. Epub 2008 Jun 12.

Pyloric stenosis

Cite this article as:
Erin Sharwood. Pyloric stenosis, Don't Forget the Bubbles, 2016. Available at:

Key points:

  • Think of pyloric stenosis in a vomiting infant.
  • Only about 1 in 7 cases will have the classic triad of projectile vomiting, visible peristalsis and the palpable “olive”.
  • Hypokalemia suggests several weeks of symptoms.
  • Ultrasound is the most common diagnostic modality, in addition to Hx & Examination.
  • Rehydrate and correct electrolyte disturbances before operative management.

Jackson is a 5-week-old baby brought into the emergency department by his mum Gina. Over the past four days he has had increasing vomiting, and today he seems lethargic. Gina tells you he hasn’t kept anything at all down in the past 24 hours, and has had only one slightly wet nappy since last night.

On examination, Jackson looks pale and mottled. His heart rate is 180 beats per minute, and his respiratory rate is 45. He is afebrile, and his central capillary return is around 3 seconds. You decide to organise an IV cannula for a fluid bolus while continuing to take more history from Gina.

What blood tests would you like to take as you cannulate? What further questions do you have for Mum?

Gina tells you Jackson is her first baby, he was born at term has been fully breast fed. She knows that lots of babies have small vomits after feeding, so wasn’t too concerned initially. The vomit is milky, with no blood or bile. Gina notes that as soon as Jackson vomits he seems hungry and extremely eager to feed again right away. Jackson usually has one or two soft yellow bowel motions a day, and hasn’t had any diarrhoea. Gina doesn’t know of any family history on her side, but isn’t sure about Jackson’s father’s side as they live overseas.

Happily, your cannula goes in beautifully, but yields only enough blood for a venous blood gas. Now what?

While you run through a fluid bolus of 10mL/kg of 0.9% sodium chloride, you take the opportunity to examine Jackson a little further. You find he has a slightly sunken anterior fontanelle. He is sleepy, but sucks vigorously at the pacifier Gina has provided. His abdomen is soft, and you can’t feel any masses in the supine position. There is no respiratory distress, and his lung fields are clear, with dual heart sounds and no murmurs.

What do you expect the gas to show?

As you finish your examination, your blood gas result becomes available. It shows a pH of 7.50, a pCO2 of 50, with a bicarbonate of 38, and a base excess of +5. The electrolytes provided on the gas readout show a sodium of 129, potassium of 3.6, and a chloride of 92.

Jackson has picked up following his fluid bolus, and is now looking for a feed. While keeping maintenance fluids running, you suggest to Gina that offering a breast feed might actually help you confirm the diagnosis. In the meantime, you decide to ask the sonographer if they can help out with an abdominal ultrasound.

As you head back to the room, you run into the surgical registrar and ask them to come and take a look at Jackson. You both note that after the feed, you can see waves of peristalsis across Jackson’s epigastrium going from left to right. You step away just in time to narrowly miss Jackson vomiting forcefully, with milky vomit making it across the cubicle to hit the wall 2 metres away!

The surgical registrar agrees this is very likely pyloric stenosis, and shows you how to palpate his right upper quadrant with Jackson resting prone on her hand. She is suitably impressed by Jackson’s presentation, and happily accepts his care, though she asks you to cancel the ultrasound as she is so confident of the diagnosis. She explains to Gina that Jackson will need surgery to release the muscle between his stomach and duodenum, but first he will need to be rehydrated over night.

Jackson went on to have a laparoscopic pyelomyotomy the following day, with no complications. As they are leaving, they come by to say goodbye, and to let you know it turns out Jackson’s dad also had pyloric stenosis at around about the same age.

What about POCUS?

Sivitz et al established a prospective study assessing the accuracy of POCUS for diagnosis of Pyloric Stenosis; it’s an interesting comparator, but essentially the vast majority of the scans were done by a only one of the participants. It’s also worth noting that the sonographic features become more marked as the stenosis progresses – in the study this meant that all POCUS-negative, sonographer-positive scans were given a free pass. The data suggest that POCUS is suitable as a rule-in test, but is not appropriate for excluding Pyloric Stenosis.

Practice Points

Idiopathic Hypertrophic Pyloric Stenosis typically occurs between 2 and 12 weeks of age, and is around 4-6 times more common in boys, particularly if they are first-born. A family history is often present.

Historically, the diagnosis was made clinically, with a ‘classic triad’ of projectile vomiting, visible peristalsis and a palpable ‘olive’ (the thickened pylorus) in the right upper quadrant at the border of the rectus abdominus muscle. More recently (possibly due to a trend toward earlier presentation to hospital), the ‘olive’ is often not easy to palpate, and ultrasound examination is often employed to confirm the suspected diagnosis. Gotley et al found At least one classic symptom or sign was present in 87% of infants but only 1 in 7 cases had the ‘classic triad’.

Blood gas analysis classically reveals a hypochloraemic metabolic alkalosis. Studies suggest hypokalaemia often doesn’t occur until 3 weeks worth of vomiting. A retrospective study of blood gas results showed that a pH of >7.45, a base excess of >+3, and a chloride of <98 were particularly useful in predicting the diagnosis in babies presenting with vomiting.

Metabolic disturbance needs to be corrected prior to surgery, as this dramatically reduces the risk of intra- and post-operative complications.



Gotley, LM, Blanch, A, Kimble, R, Frawley, K, and Acworth, JP, “Pyloric stenosis: A retrospective study of an Australian population” Emergency Medicine Australia 21 (2009) 407-413.

Taylor ND, Cass DT, Holland AJ. Infantile hypertrophic pyloric stenosis: has anything changed? J Paediatr Child Health. 2013 Jan;49(1):33-7. doi: 10.1111/jpc.12027. Epub 2012 Dec 2.

Sivitz et al. Evaluation of Hypertrophic Pyloric Stenosis by Paediatric  Emergency Physician Sonography Acad Emerg Med. 2013 Jul;20(7):646-51. doi: 10.1111/acem.12163. Epub 2013 Jun 19.

Oakley EA and Barnett PLJ, “Is acid base determination an accurate predictor of pyloric stenosis?” Journal of Paediatrics and Child Health 36 (2000), 587-589.